January 5, 2009

The New Year has brought several important changes to the Medicare Physician Quality Reporting Initiative. Whether you participated in the PQRI in 2008 and plan to continue or whether you are ready to begin reporting the PQRI measures in 2009, we would like to summarize the changes for you.

The Bonus Amount Will Increase from 1.5% to 2.0%

“Eligible Providers,” including anesthesiologists, certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs) who report “successfully” under the PQRI program will earn a bonus amounting to 2% of their total Medicare allowed charges. If your group’s combined total of Medicare allowed charges for 2009 turns out to be, for example, $250,000, you may earn a bonus of $5,000.

“Successful reporting” involves reporting the appropriate PQRI code on the claim for at least 80% of a minimum of three quality measures. Only two measures apply to anesthesia services. You do not need to report the general minimum of three, but you will need to report successfully on the two available measures.

The Timely Administration of Antibiotic Prophylaxis Measure (#30) Should Be Reported With Specific Anesthesia Codes

The Centers for Medicare and Medicaid Services (CMS) normally determine whether a physician has met the 80% threshold for each measure by calculating “the percentage of a defined patient population that receives a particular process of care or achieves a particular outcome.” The quality measures typically include a denominator (eligible case) and a numerator (clinical action).

Until now, whether a given anesthetic was an “eligible case” depended on the existence of an order for prophylactic antibiotics. The flaw here was that cases in which no anesthetic was delivered were not part of the denominator. If there was no order, there was no denominator code to place on the claim form. If an order had not been executed, no numerator code was going to be reported for that case either. Consequently the anesthesiologists’ overall performance rate would always equal 100 percent.

Using anesthesia codes for the denominator takes care of this problem. Medicare claims processing systems will check for an anesthesia CPT™ code from the following list:

00100, 00102, 00103, 00120, 00140, 00145, 00147, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00350, 00352, 00400, 00402, 00404, 00406, 00450, 00452, 00454, 00470, 00472, 00474, 00500, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00622, 00625, 00626, 00630, 00632, 00634, 00670, 00700, 00730, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00820, 00830, 00832, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 01120, 01140, 01150, 01170, 01173, 01180, 01190, 01202, 01210, 01212, 01214, 01215, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01360, 01382, 01392, 01400, 01402, 01404, 01430, 01432, 01440, 01442, 01444, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01500, 01502, 01520, 01522, 01610, 01622, 01630, 01632, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01710, 01712, 01714, 01716, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01924, 01925, 01926, 01951, 01952, 01953, 01961, 01962, 01963, 01965, 01966, 01968, 01969

The “clinical action” codes for the numerator are as follows:

• 4048F -- Prophylactic Antibiotic was Given Within Specified Timeframe
• 4048F with modifier 1P (4048F-1P) -- Prophylactic Antibiotic not Given for Medical Reasons (e.g., contraindicated, patient already receiving antibiotics)
• 4047F-8P -- Prophylactic Antibiotic not Ordered
• 4048F-8P -- Prophylactic Antibiotic Ordered but not Given Within One Hour/Two Hours, Reason not Specified
• Swan-Ganz Catheter Insertions Are Added to the List of Procedures for Which You Should Report Compliance With the Protocol for Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Measure #76

Code 93503, insertion and placement of flow-directed catheter (e.g., Swan-Ganz) for monitoring purposes, is now on the list of denominator codes for Measure #76, Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous Catheter Insertion Protocol. This makes Measure # 76 much more important in anesthesiology practice than it was in 2007 or 2008, when it was only reported with the codes in the 365XX series, insertion of a central venous catheter.

A second change to Measure #76 is the addition of the parenthetical at the end of the description of the measure:

"Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current guideline)] followed”

Allowing the substitution of acceptable alternative antiseptics for 2% chlorhexidine may facilitate reporting.

The clinical action codes for the numerator for Measure #76 are the following:

• 6030F – All elements of Maximal Barrier Technique (cap And mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis or acceptable alternative antiseptics per current guideline) followed
• 6030F-1P – protocol not followed for medical reason(s) (including CVC insertion performed on emergency basis). Document the reason in the anesthesia record
• 6030F-8P – all elements of Maximal Barrier Technique not followed, reason not otherwise specified.

We hope that this explanation of the 2009 changes that will have the greatest impact on anesthesiologists’ PQRI reporting will be helpful to you. ABC clients with questions about the PQRI should contact their account managers. If you are not a current client of ABC and would like further clarification please call 517-787-6440 x 4113 or send an email to info@anesthesiallc.com.